Medication errors: Cut your risk with these tips

Reduce your risk of medication errors by asking questions and being informed about the medications you take, including possible side effects and adverse interactions.

By Mayo Clinic staff

Medication errors may sound harmless, but mistakes in prescribing, dispensing and administering medications injure more than 1 million people a year in the United States. Yet most medication errors can be prevented. How can you protect yourself and your family?

One of the best ways to reduce your risk of being harmed by medication errors is to take an active role in your health care. Learn about the medications you take — and take responsibility for monitoring their effectiveness and side effects. Never hesitate to ask questions or share concerns with your doctor, pharmacist and other health care providers.
Medication errors 101

Just what are medication errors? Medication errors are preventable events that lead to inappropriate medication use. Medication errors that cause injury or harm are referred to as adverse drug events. An example of a medication error is taking trimethoprim-sulfamethoxazole (a combination of two antibiotics) when you're already taking warfarin (a blood thinner). The combination can lead to dangerous levels of blood thinning. Another example is taking over-the-counter acetaminophen at the same time as you're taking a prescription pain medicine that contains acetaminophen, thus possibly exceeding the recommended dose and putting yourself at risk of liver damage.

Although medication errors can happen anywhere, including your own home, they most commonly occur in doctors' offices, hospitals and pharmacies. When all types of errors are taken into account, a person in the hospital can expect on average to be subjected to one medication error a day. However, the actual rates vary widely across facilities. Knowing what you're up against can help you play it safe. The most common causes of medication errors are:

* Poor communication between health care providers
* Poor communication between providers and patients
* Sound-alike medication names and medical abbreviations
* Illegible prescriptions or confusing directions

Understand the lingo

Good communication is a two-way street. If you don't understand something your doctor says, ask for an explanation. Don't be afraid to say if you didn't understand some of the words or explanation. To give you a leg up, here are a couple of basic terms defined:

* Adverse effect. An unwanted and possibly harmful symptom caused by a medication.
* Side effect. An unintended result of a medication. Side effects can be beneficial, such as weight loss caused by a medication for diabetes. However, when doctors talk about side effects they usually mean adverse effects.
* Drug interaction. The way a medication works can be altered by other drugs (prescription and nonprescription, or over-the-counter), supplements, foods and beverages (including alcohol). These interactions may make the medication not work as well, work too well or may cause side effects.

Get answers

Being active in your care means educating yourself. Whenever you start a new medication, make sure you know the answers to the following:

* What is the brand or generic name of the medication?
* What is it supposed to do? How long will it be until I see results?
* What is the dose? How long should I take it?
* Are there any foods, drinks, other medications or activities I should avoid while taking this medicine?
* What are the possible side effects? What should I do if they occur?
* What should I do if I miss a dose?
* What should I do if I accidentally take more than the recommended dose?
* Will this new medication interfere with my other medication(s) and how?
Speak up

Asking questions is essential, but it isn't sufficient. You also have to share information with your doctor and pharmacist, especially if you're getting a new prescription or seeing a new doctor. Here's what you need to tell your health care providers:

* The names of all the medications you're taking, including over-the-counter products and supplements
* Any medications that you're allergic to or that have caused problems for you in the past
* Whether you have any chronic or serious health problems
* If you might be pregnant or you're trying to become pregnant

Don't make the same mistake

The following are examples of medication errors that can happen at home. They come from real people's experiences. Learn from them and don't make the same mistakes:

* Confusing eardrops and eyedrops. Always double-check the label. If a medication says "otic" it's for the ears. If it says "ophthalmic" it's for the eyes.
* Chewing nonchewables. Don't assume chewing a pill is as good as swallowing it. Some medications should never be chewed, cut or crushed. Doing so may change how they're absorbed by the body. Review the labels or ask your doctor or pharmacist how to take your medications.
* Cutting up pills. Never split pills unless your doctor has told you it's safe to do so. Some medications shouldn't be cut because they're coated to be long acting or to protect the stomach.
* Using the wrong spoon. The spoons in your silverware drawer aren't measuring spoons. Most silverware spoons vary in the amount of liquid they can hold, meaning you could get too much or too little medication. To get an accurate dose, use an oral syringe (available at pharmacies) or the dose cup that came with the medication.

Make safety a habit

Get into the habit of playing it safe with these medication tips:

* Keep an up-to-date list of all your medications, including nonprescription and herbal products.
* Store medications in their original labeled containers.
* Save the information sheets that come with your medications.
* Use the same pharmacy, if possible, for all of your prescriptions.
* When you pick up a prescription, check that it's the one your doctor ordered.
* Don't give your prescription medication to someone else and don't take someone else's.

A final word

"Don't ask, don't tell" is never a smart policy when it comes to medications and your health. Don't hesitate to ask questions or to tell your health care providers if anything seems amiss. Remember, you're the final line of defense against medication errors.

Everything you need to know about menopause

Is estrogen safe this week? Does it matter when you start hormone therapy? What does "bioidentical" mean, anyway? Mary Duenwald scours the latest science for the answers even your doctor may not have.

In a windowless high school auditorium a few blocks from where Highways 6 and 50 intersect in Delta, Utah, you could hear the rain and thunder picking up steam. But for 100 or so women attending a menopause workshop one Sunday, the storm was inside, where the topic of a lecture was about how changing hormones affect sex drive—not the sort of thing people usually talk about in this rural community of alfalfa hay farmers. The speaker was just opening the discussion for questions when the power went out. "It was just so perfect. Suddenly, hands went up everywhere and the women were asking all kinds of questions they wouldn't have been willing to ask when the lights were on. One wanted to know about orgasm—really personal questions," recalls Linda Ekins, 60, the registered nurse who organized the event.

That was five years ago; today the workshop has expanded into an annual conference called Women in Motion that draws 250 to 300 attendees. The idea came to Ekins when she realized she wasn't alone in having to bushwhack her way through menopause. All across the country, millions of women are dealing with the end of fertility, many of them muddling along in discomfort and frustration. It isn't just a jarring reminder that one is aging; it can also wreak havoc on the body—and the mind. Sudden outbursts of temper, creeping anxiety, depression, loss of passion, or foggy thinking sends many sufferers in search of psychological help; others rush to trainers when their waistlines start expanding; still others go crazy buying supplements to combat thinning hair and painful joints. And often these women don't realize that the real cause of these symptoms—not to mention hot flashes, night sweats, vaginal dryness, and insomnia—is the onset of menopause, which officially starts after 12 consecutive months of having no menstrual periods.

Scientists have yet to figure out why declining levels of estrogen (which occurs when the ovaries stop producing eggs) should have such wide-ranging effects. But they do know that cells throughout the body have receptors for the hormone and that its withdrawal impacts everything from the blood vessels to the brain. "The layperson has very little information about this," Ekins says. "My women are confused. They're having hot flashes. They're bitchy with their husbands, grouchy with their kids, angry at the world, absolutely miserable." And ebbing libido—particularly how it's affecting their marriages—is a huge concern (a course called "Hormones in the Bedroom" drew a standing-room-only crowd a couple of years ago). "My aim is to give women information, so they can visit with their physicians and intelligently come up with a plan," she says. "We do not need to be afraid. We need to be educated."

And yet even smart, well-informed women often hit a wall when it comes to deciding which symptoms are menopausal and how to deal with them. Hormone therapy (HT)—specifically supplemental estrogen, alone or combined with progesterone (usually progestin)—is the most studied and effective form of treatment to date for symptoms such as hot flashes and night sweats. But the treatment developed a bad reputation in 2002 after the Women's Health Initiative (WHI)—which conducted the largest, most rigorous study ever on HT—issued alarming findings that taking estrogen and progestin could increase the risk of both breast cancer and heart disease. In addition, it later came out that the hormones didn't seem to help much with sleep, depression, energy, or sexual satisfaction compared with a placebo. "There is still a lot of confusion even among physicians about hormone therapy, and many avoid prescribing it," says JoAnn Manson, MD, chief of preventive medicine at Harvard's Brigham and Women's Hospital and a principal investigator of the WHI study. "It can be a real problem for women to find a doctor who is willing to discuss all the benefits and risks of hormone therapy."

To more safely and comfortably navigate this major phase of life, it helps to understand a bit about past hormone research and what science is discovering even as we speak.

Hormone History

It was back in 1966 that Robert Wilson, MD, a Brooklyn gynecologist, published his best-selling book, Feminine Forever, and declared that taking estrogen was a postmenopausal woman's best chance to lead a healthy, happy, and sexually active life. In the ensuing decade, prescriptions for the hormone almost doubled. But then came evidence that taking estrogen could lead to uterine cancer, and prescriptions dropped off dramatically.

Hormone therapy regained its popularity, however, after the discovery that adding progestin headed off the risk of uterine cancer. In the early 1980s, scientists began to focus on how estrogen could protect women's bones against osteoporosis. By the '90s, research seemed to confirm its long-suspected link to preventing heart disease, at which point the American Heart Association and the American College of Physicians came onboard. Once again, hormone therapy looked like a smart idea.

But in 2002, the Women's Health Initiative caused scientific whiplash. According to its findings, the hormone pills in question—Prempro, the most popular brand of estrogen and progestin—not only failed to protect against heart disease but actually raised the risk. Crunching the data, the researchers projected that among 10,000 women taking these hormones for a year, compared with a placebo, there would be seven more cases of coronary heart disease, eight more cases of stroke, and 18 more cases of blood clots. "There was much rending of clothes and gnashing of teeth when this study came out, because the results were very unexpected," says Nanette Santoro, MD, director of reproductive endocrinology and infertility at Albert Einstein College of Medicine, in the Bronx.

Less shocking but more unnerving for many: Among 10,000 women on Prempro, there would also be eight additional cases of invasive breast cancer. (The fact that there was a lower risk of colorectal cancer and hip fractures got lost in the shuffle.)

The WHI findings made major headlines and were particularly scary to the public, given that researchers stopped the study three years early to protect participants' health. Women by the millions threw out their hormone pills. And seven years later, many are still wary. "I can understand the mistrust," says Carla Lupi, MD, an assistant professor of clinical obstetrics and gynecology at the University of Miami Miller School of Medicine. "These women grew up being told that hormone therapy was the greatest thing since sliced bread, only to wake up and be told that there actually are some risks."

Unfortunately, scientists have yet to unearth a more effective remedy than estrogen, and that may reflect what's been a relatively narrow approach to the profound mind-body shifts that occur during menopause. "All of this focus on estrogen may be a bit misplaced," says Lisa Sanders, MD, clinical instructor at Yale University School of Medicine. "Women exist in an incredibly complicated hormonal milieu during menopause. Estrogen declines, but so does testosterone, which is why libido goes down. We're also losing hormones that we really don't know much about, and we haven't asked the questions."

The fact is, however, researchers do know a lot more about hormone therapy today. Since the WHI shake-up, they have begun to explore—and shed light on—how the formulation and timing of HT may lower its risks and improve its benefits. And the result is a more nuanced knowledge of how the treatment might be most safely applied.

The Bioidentical Option

Vivian Torres-Suarez, 54, a healthcare executive from Queens, New York, was one of millions of women suspicious of hormone therapy in the wake of the WHI findings. But her symptoms were getting to her—not only hot flashes but also a hot temper that had prompted her to lash out at a colleague during a staff meeting. "I don't remember exactly what he said, but I must have turned into a wicked witch," Torres-Suarez recalls. "Then he said, 'Are we having a bad menopausal day?' And I just blasted him."

Torres-Suarez's gynecologist recommended the estrogen pill Premarin, which contains the same type of estrogen used in the WHI study. "I don't feel comfortable with that, I really don't," Torres-Suarez told her doctor. And there are experts who would agree with that choice, arguing that Premarin and Prempro are not ideal products because they're derived from the urine of pregnant horses. Instead, these doctors prefer a synthetic estrogen, estradiol (found in Estrace, Climara, Estring); it's chemically identical to the kind made by women's ovaries, which is why it is described as "bioidentical." Between 2003 and 2008, prescriptions for bioidentical estradiol-based products rose from 22 to 35 percent of the supplemental estrogen market while those for Premarin tablets fell from 53 to 35 percent, according to IMS Health, a healthcare information and consulting company.

Manhattan internist Erika Schwartz, MD, prescribes estradiol made by pharmaceutical companies or orders a transdermal cream from a compounding lab, which customizes it for individual patients. When Torres-Suarez visited Schwartz for a second opinion, the bioidentical hormones made sense to her, and she liked the idea of a cream (hers includes bioidentical progesterone), which she applies to her chest twice a day. "My hot flashes haven't disappeared, but they're much better," she says. "And I'm no longer like the girl in The Exorcist. I felt like I was losing my mind, and I'm not like that—I'm really a nice person. This has absolutely made me better."

Yet, whether bioidentical estrogen and progesterone are safer or superior is unproved. It's entirely possible that they have the same risks that Prempro does. "There was a flight from reason when the WHI results were published," says Santoro, referring to the illogical assumption that if a hormone product wasn't used in the study it must therefore be safe. She adds: "To prescribe something more physiologic may make sense, but what's really physiologic for a 55-year-old woman is to have less hormone, period."

Kirtly Parker Jones, MD, a professor of reproductive endocrinology at the University of Utah, in Salt Lake City, points out another important fact of biology. The body often takes the estrogen it's given and changes its form so that a woman may use estradiol only to have her body turn it into estrone sulfate, the main ingredient in Premarin and Prempro. "Some well-meaning practitioners probably don't know the endocrinology," Jones says. One trial in the works called the Kronos Early Estrogen Prevention Study (KEEPS) is giving some subjects estradiol patches and others Premarin pills, with the goal of determining whether the patch is as effective as, and potentially safer than, the pill. But the results aren't expected until 2012.

In the meantime, a number of practitioners who are deeper into the bioidentical movement are stirring up controversy by measuring the hormone levels in women's saliva, a method unproven by mainstream science, in order to concoct products that may contain mixtures of various kinds of bioidentical hormones, as well as ingredients that have not been approved by the Food and Drug Administration. Last January the FDA took action, sending warning letters to seven compounding pharmacies stating that their claims of producing drugs that are safer, more natural, and superior to FDA-approved HT drugs are "false and misleading" and unsupported by medical evidence. In particular, estriol, one form of estrogen used by these pharmacies, has never been approved by the FDA, and its safety and effectiveness are unknown.

The Risks of Hormone Therapy

For many women, the specter of breast cancer is what drives them away from HT—and for those who have a higher-than-average risk of the disease, such fears make sense. The link between HT and breast cancer has been supported by studies in the United States, Sweden, and the United Kingdom.

While finessing the chemistry of estrogen won't likely mitigate the breast cancer risk, tinkering with the progestin component of HT might. "Study after study seems to indicate that the increased risk of breast cancer is not related to estrogen but to progestin," says Steven R. Goldstein, MD, a professor of obstetrics and gynecology at New York University School of Medicine. A separate component of the WHI study in which subjects were not given progestin (because they'd had hysterectomies and stood no risk of uterine cancer) did not show an increase in breast cancer risk.

Goldstein has begun to experiment with prescribing his patients much less progestin, while regularly monitoring their uterine lining with ultrasound—the idea being that a smaller amount of the hormone may be enough to prevent cancer there. Still, he makes clear, "there has been no long-term study of this methodology."

When it comes to heart disease risk, the research is most promising. Because the WHI was designed in part to investigate HT's effect on heart disease, the researchers chose mostly women who were older (and more likely to have cardiac events); the average age of the 27,347 subjects was 63, and a majority of them were at least ten years past having their last menstrual period. But now a new theory has taken shape and steadily gained credibility: that hormones might be less dangerous, and perhaps even beneficial, if started closer to the time women reach menopause (the average age is 51). According to this new theory, estrogen introduced before too much plaque begins to build in a woman's arteries might actually help keep blood vessels healthy. Only after the plaques have gained a foothold might HT make things worse. Further analyses of the WHI data support this idea. As it turns out, a subgroup of younger women in the estrogen-alone study had a significantly reduced risk of heart attacks and cardiac death; those with the increased risk were the ones who'd started hormones more than 10 years beyond menopause.

A New Approach: Start Early

Starting HT earlier might also positively affect memory, concentration, and cognition. Alas, here again there is no good clinical trial data. But a half-dozen small studies have had promising results, says Sarah Berga, MD, chairwoman of the department of gynecology and obstetrics at Emory University School of Medicine in Atlanta. "Estrogen seems to lubricate the brain, in some ways, for thinking," she explains.

Better evidence for—or against—early timing may arrive when the KEEPS study, whose subjects range in age from 42 to 58, is completed. "What I hope the study will show," says Santoro, one of its principal investigators, "is that for women close to menopause, the risks of hormone therapy are low and they may get some cardio protection."

There is already a growing consensus around this idea. Many leading experts now recommend HT at the lowest dose and for the shortest time possible—the first few years of menopause—along with regular checkups and mammograms for women with debilitating symptoms (assuming they don't have high risk of heart disease or breast cancer). Manson recommends staying on hormones two to three years, five at the most, after which hot flashes usually subside. "Five to 10 percent of women have persistent significant symptoms more than ten years after menopause," she says; in those cases, doctors and patients must weigh the individual health risks against quality of life benefits. "But the vast majority of women can come off HT after a few years and do fine." This, by the way, is now the position of the North American Menopause Society and the American Association of Clinical Endocrinologists.

But we still have a long way to go in terms of getting the answers we need—which means that women really must take the steering wheel in directing their care. For Linda Ekins, the nurse in Utah, menopause has been a challenging journey. "It's not just about medication," she says, explaining that her menopausal troubles started 20 years ago with depression. "I couldn't figure out what was going on. I went into therapy and realized that part of it was menopausal." When hot flashes came soon after, she was able to keep them at bay by taking the herbal supplement dong quai (although research has failed to prove it a reliable treatment). "But at 55," she says, "the hot flashes were breaking through, and I wanted information." She'd read about bioidentical hormones and found her way to the University of Utah's Kirtly Parker Jones, who prescribed them to her in a progesterone pill and estrogen patch. "I asked for the lowest dose possible, and Dr. Jones said I could try cutting the patch in half. I did, but then I started having hot flashes again, so I've gone back to the full dose. The hormones have done really well for me, including helping vaginal dryness, which I don't choose to experience because I'm still sexually active; as long as my husband is happy and I'm happy, things are good." But, she adds, there's so much more to managing menopause on an emotional and spiritual level. To that end, Ekins has expanded her conference by bringing in experts in yoga and energy work. "Find friends and support systems," she urges. "A pill or patch can certainly help, but it won't be the answer to everything."

Is Your Medicine Making You Fat?

It's the side effect nobody thinks about until they look down and realize—hello!—they've gained 10, 20, 30 pounds. Yet almost any medication, from antidepressants to antihistamines, has the potential to make you ravenous or sluggish, or meddle with your metabolism. Here are the worst offenders and how to fight back.

Mired in depression and a vicious work dispute, Barbara Tunstall placed her hopes on the antidepressant Remeron. Her doctor warned that food cravings were a potential side effect of the drug, but the 45-year-old Maryland insurance specialist put such concerns aside—initially. Tunstall felt so much better on Remeron that she soon found the energy to resolve her work troubles. Then she realized that she was gaining weight at an alarming pace: Just six months into her treatment, she had put on 30 pounds.

"I'd eat anything in my way," she says. "I knew I was out of control, but I still couldn't stop." Tunstall and her psychiatrist tried to rein in her constant eating—including adding a course of Topamax, an antiseizure medication known for its ability to suppress appetite—and yet nothing helped. The weight gain was adding a whole new list of frustrations and anxieties. Finally, her doctor weaned her off Remeron in favor of the antidepressant Celexa, a milder drug. Her cravings subsided, and Tunstall gradually shed the weight.

Fewer than 5 percent of Americans who are overweight got that way because of their medications, suggests research by Louis Aronne, MD, director of the Comprehensive Weight Control Program at New York-Presbyterian Hospital/Weill Cornell Medical Center, and a past president of the North American Association for the Study of Obesity. That's not a staggering number, but doctors are concerned nonetheless. Heart disease, diabetes, depression, and cancer are on the rise, and it's the drugs used to treat them that are most likely to pack on the pounds. "I think this is an underrecognized problem," says Aronne. "Most of the people we see simply aren't aware of the relationship between their weight and the drugs they're taking and that it's something they need to watch."

Some drugs drive up weight by making you drowsy or lethargic, which means you'll burn fewer calories throughout the day. Others affect brain chemistry in a way that trips hunger switches. Because everyone reacts differently to these drugs, it's virtually impossible to predict how much you might gain during treatment. What's more, remedies that aren't known for adding pounds still could. "Almost any medication can cause changes in weight," says Lawrence Cheskin, MD, an associate professor at the Johns Hopkins Bloomberg School of Public Health and director of the Johns Hopkins Weight Management Center. "Generally speaking, people who are sick lose their appetite. So when they're successfully treated for an illness, they may begin to eat more. If you're not aware of that consequence, it's easy to go overboard."

The best way to preserve your shape is to monitor yourself closely. "Anytime you start a new therapy, weigh yourself every morning," says George Blackburn, MD, PhD, associate director of the division of nutrition at Harvard Medical School, where he teaches a course that includes a section on drugs and weight gain. "Five pounds is your red flag to check with a physician." Act sooner if you suddenly feel excessively hungry or lethargic. You may have the option of changing prescriptions. "Increasingly, drugs linked to weight problems are being replaced with second-generation alternatives," Blackburn explains. Some are so new that your family physician may not be aware of them, so consider seeing a specialist. A doctor who's trained to treat your specific problem, or at least an internist or an endocrinologist with an interest in obesity issues, will be up on the latest treatments.

In some cases, switching drugs—or readjusting the dosage—isn't an option. But according to Blackburn, eating 100 to 200 fewer calories each day is enough to counteract the kind of weight gain you'd experience on most drugs, especially if you increase your exercise. Below, the drugs most likely to tip the scale and what you can do about it.

Antidepressants: Tricyclic medicines can add as many as nine pounds a month; lithium-based mood stabilizers, two and a half pounds. Another class of antidepressants, SSRIs, target the mood-and-appetite-related neurochemical serotonin and may also cause weight gain. If you begin to gain on one of these, look into switching to a bupropion drug; these target neurochemicals that don't increase hunger.

Antipsychotics: Haloperidol and clozapine can have a big effect on metabolism and appetite, adding as many as five pounds a week. Usually people on these drugs are already being closely monitored by a psychiatrist, so if the pounds start to add up, don't hesitate to ask about alternatives such as atypical antipsychotics, which appear to be weight neutral.

Antihistamines, Sleep Aids: Many over-the-counter allergy remedies and sleeping pills contain diphenhydramine, an ingredient that can leave you drowsy during the day and interfere with your sleep patterns at night, reducing the number of calories you're burning.

Blood Pressure Medication: Both alpha- and beta-blockers can cause fatigue, which may add pounds in some patients (the amounts reported vary wildly). If your energy fades, look into ACE inhibitors and calcium channel blockers.

Cancer Therapy: Women with breast cancer are likely to gain weight during chemotherapy. The exact reasons for this are poorly understood, but doctors believe the treatment can slow metabolism.Also, the anti-estrogen drug tamoxifen may increase appetite; Decadron, a steroid used on cancer patients, is another potential culprit. Additionally, chemotherapy often induces early menopause, which can add pounds. Switching drugs isn't an option, so work with your doctors to develop an eating-and-exercise plan.

Diabetes Drugs: Insulin helps process blood sugar by depositing it into cells. Insulin and drugs known as sulfonylureas can bring on bouts of hypoglycemia (low blood sugar), which stimulates appetite. Some patients report gaining up to 11 pounds during the first three to 12 months of treatment. Ask about weight-neutral medications, such as metformin.

Migraine Medicines: Those based on valproic acid can stimulate hunger. These days, doctors are more likely to prescribe Topamax or Imitrex. Neither medicine is associated with weight gain, and both are thought to be safer overall.

Steroids: Oral corticosteroids, commonly used to treat conditions like rheumatoid arthritis and chronic inflammation, add pounds in multiple ways. They rob calories from your energy stores and send them to fat cells. So not only are you adding pounds but your energy is being compromised, which drives up your cravings. Some people gain as many as 28 pounds on steroids. Ask about switching to prescription-strength NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen.

If you gain weight due to medication, the key is patience. "When you go off the drug, you won't lose weight as fast as you gained it," says Aronne. "But by taking control of this aspect of your treatment, you'll start to see results."

Sara Reistad-Long is a writer living in New York

Five Steps to Digestive Health

The digestive system is a lot like a car or a computer. A lot of things have to go right for it to work properly. And when one thing falters, the whole system can turn your gut into a tornado of trouble. Luckily, there are enough data about the liver and pancreas to show that you can help them function to their fullest potential to promote good digestive health and also to avoid the troubles that can come when things get out of whack.

Step 1: Live Clean

While it's impossible to stay entirely toxin-free throughout your everyday life, that doesn't mean you can't take steps to help reduce the pollution that pummels your body. Lessen the load for the liver, and you'll live longer.

So what's that mean? Choose charcoal-filtered purified water over unfiltered tap water. Choose unrefined and unprocessed foods over the ones that spend more time in a factory than in the earth. Choose fruit over Froot Loops. Choose proteins like lentils, soy, beans, nuts and seeds over red meats and the accompanying animal fats to avoid consuming the toxins that those animals were exposed to. And avoid eating any liver of any species that has been exposed to toxins. Your liver—not to mention your heart, your brain and your waistline—will thank you.

Also, have protected sex and use new needles and new pigment for tattoos, as hepatitis B and C are transmitted this way.

Step 2: Add the Crunchy Veggies

You already know cruciferous vegetables—broccoli, cauliflower, brussels spouts and cabbage—are good cancer fighters. They've also been shown to help aid the detoxification processes of the liver.

While you're at it, it's also important to have foods loaded with vitamins B, like whole grains, and C, like citrus fruits and leafy green vegetables. They, too, have been shown to aid the detoxification process by helping your innate antioxidant system.

Step 3: Sprinkle on Some Health

Ginseng, cinnamon, coffee and tea have been shown to help increase insulin receptivity, which can help lower the risk of aging from type 2 diabetes. Some studies have shown that one of the substances in ginseng berries—not the root—or a half teaspoon of cinnamon a day can increase insulin function by more than 50 percent.

Step 4: Get These Nutrients

Have trouble managing those confusing store shelves?
Get your liver and pancreas functioning at their fullest potential. Promote good digestive health and avoid
digestive troubles with these nutrients and supplements.

NUTRIENTS
Lecithin
This is a supplement that contains 10 percent to 20 percent phosphatidylcholine, depending on the brand.
Phosphatidylcholine is a necessary component of VLDL, or very-low-density lipoprotein, which transports fats
processed by the liver around the body.
One component of the chemical, called choline, comes from the diet and can help replenish the needed levels of
phosphatidylcholine in the liver to build VLDL molecules. However, when people are deficient in choline, these
VLDL particles cannot form correctly, so fat builds up in the liver to cause damage. There are two ways to get
choline or phosphatidylcholine—through a supplement or in food.
A varied diet should provide enough choline. Men should aim for 550 milligrams and women for 425 milligrams a
day. One large egg contains about 125 milligrams of choline, and one cup of toasted wheat germ contains about
175 milligrams.
Zinc
Zinc has been shown to help detoxify the body of alcohol. The optimum amount, especially for anyone who
drinks alcohol, is 15 milligrams per day.
SUPPLEMENTS
These should be taken with the guidance of a doctor or herb expert because of their lack of standard dosing and
potential interaction with other drugs. Two to consider are:
Milk thistle
It’s considered the safest and best supplement for liver health. Milk thistle’s powerful ingredients, flavonoids,
protect against inflammation and an unhealthy thickening of the liver. They also may help prime the body’s
immune system and antioxidant system.
Though its use is not supported by the reams of data we like to see, the evidence does suggest some positive
effects, as well as confirms its safety. The dose is 80 to 200 milligrams one to three times a day.
Dandelion
A member of the sunflower family, it’s one of the most nutrient-rich plants there is. The whole plant is edible, but
the herb is a source of potassium, sodium, phosphorous and iron, as well as vitamin A.
The recommended supplement dose is 900 milligrams a day. Dandelion has a number of laboratory studies to
suggest that it protects hepatocytes. However, good clinical data from humans are lacking.
As a reminder, always consult your doctor for medical advice and treatment before starting any program.

Step 5: Don't Toxify the Detoxifier

Vitamin A can cause fat storage in the liver, chronic hepatitis and cirrhosis. Patients with chronic liver disease should consume less than 2,500 IU of vitamin A per day in pill form. Getting vitamin A through food seems okay. A list of other nutrients and supplements that have been shown to have toxic effects on the liver:

• Nicotinic acid (niacin; Nicolar)
• Pennyroyal oil
• Senna fruit extracts
• Valerian
• Iron
• Mistletoe

Flat Belly Diet Smoothies

Flat Belly Diet Recipes

Mango Surprise Smoothie

Avocado lends this refreshing drink a silky smoothness.

SERVINGS: 1

¼ cup mango cubes

¼ cup mashed ripe avocado (MUFA)

½ cup mango juice

¼ cup fat-free vanilla yogurt

1 Tbsp freshly squeezed lime juice

1 Tbsp sugar

6 ice cubes

Combine the mango, avocado, mango juice, yogurt, lime juice, sugar, and ice cubes in a blender. Process until smooth. Pour into a tall glass. Garnish with sliced mango or strawberry, if desired, and serve.

Nutritional Info Per Serving

268 calories, 5 g protein, 53 g carbohydrates, 6 g fat, 1 g saturated fat, 1 mg cholesterol, 84 mg sodium, 4 g fiber

Blueberry Smoothie

A berry-licious breakfast or snack, perfect for the Flat Belly Diet jumpstart

SERVINGS: 1

1 cup skim milk
1 cup frozen unsweetened blueberries
1 Tbsp cold-pressed organic flaxseed oil (MUFA)

Place milk and frozen unsweetened blueberries in blender and blend for 1 minute. Transfer to glass, and stir in flaxseed oil.

Flat Belly Diet Recipes

Peanut Butter and Banana Smoothie

Natural peanut butter lends texture to this hearty breakfast drink from the Flat Belly Diet Cookbook

SERVINGS: 1

½ cup fat-free milk
½ cup fat-free plain yogurt
2 Tbsp creamy natural unsalted peanut butter (MUFA)

¼ very ripe banana
1 Tbsp honey
4 ice cubes

Combine the milk, yogurt, peanut butter, banana, honey, and ice cubes in a blender. Process until smooth. Pour into a tall glass and serve.

Nutritional Info Per Serving

410 calories, 19 g protein, 50 g carbohydrates, 16 g fat, 2 g saturated fat, 5 mg cholesterol, 289 mg sodium, 3 g fiber

Flat Belly Diet Recipes

Vanilla Yogurt and Blueberry Smoothie

A berry sweet and satisfying Flat Belly Diet snack

SERVINGS: 1

1 cup skim or soy milk
6 oz (80-calorie) vanilla yogurt
1 cup fresh blueberries
1 Tbsp flaxseed oil (MUFA)

Handful of ice OR 1 cup frozen blueberries

Combine milk, yogurt, and fresh blueberries plus ice OR frozen blueberries in a blender. Blend for 1 minute, transfer to a glass, and stir in flaxseed oil.

Nutritional Info Per Serving

360 calories

Flat Belly Diet Recipes

Citrus Infusion Smoothie

Lemon and orange blend for a tropical Flat Belly Diet drink

SERVINGS: 1

1 cup skim or soy milk
6oz (80-calorie) lemon yogurt
1 medium orange peeled, cleaned, and sliced into sections
1 Tbsp flaxseed oil (MUFA)

Handful of ice

Combine milk, yogurt, orange, and ice in a blender. Blend for 1 minute, transfer to a glass, and stir in flaxseed oil.

Nutritional Info Per Serving

370 calories

Flat Belly Diet Recipes

Chocolate Delight Smoothie

Curb sweet cravings with this perfect MUFA-rich, Flat Belly Diet snack

SERVINGS: 1

½ cup skim or soy milk
6 oz (80-calorie) vanilla yogurt
1/4 cup chocolate chips (MUFA)

1 cup fresh raspberries
Handful of ice OR 1 cup frozen raspberries

Combine milk, yogurt, chocolate chips, and fresh raspberries plus ice OR frozen raspberries in a blender. Blend for 1 minute, transfer to a glass, and eat with a spoon.

Nutritional Info Per Serving

387 calories

Flat Belly Diet Recipes

Sweet Peach Smoothie

A smoothie makes a delicious snack on the Flat Belly Diet jumpstart

SERVINGS: 1

1 cup skim milk
1 cup frozen unsweetened peaches
2 tsp cold-pressed organic flaxseed oil (MUFA)

Place milk and frozen, unsweetened peaches in blender and blend for 1 minute. Transfer to glass, and stir in flaxseed oil.

Flat Belly Diet Recipes

Apple-a-Day Smoothie

Try this taste-bud pleasing drink from the Flat Belly Diet

SERVINGS: 1

1/2 cup skim or soy milk
6oz (80-calorie) vanilla yogurt
1 tsp apple pie spice
1 medium apple peeled and chopped
2 Tbsp cashew butter (MUFA)

Handful of ice

Combine milk, yogurt, apple pie spice, apple, cashew butter, and ice in blender. Blend for 1 minute, transfer to a glass, and eat with a spoon.

Nutritional Info Per Serving

388 calories

Flat Belly Diet Recipes

Pineapple Smoothie

A refreshing Flat Belly Diet jumpstart snack

SERVINGS: 1

1 cup skim milk
4 oz canned pineapple tidbits in juice
1 Tbsp cold-pressed organic flaxseed oil (MUFA)
Handful of ice

Place milk, canned pineapple in blender, add of ice, and whip for 1 minute. Transfer to glass and stir in flaxseed oil.

Flat Belly Diet Recipes

Strawberry Smoothie

Kick off the Flat Belly Diet 4-day jumpstart with this refreshing drink

SERVINGS: 1

1 cup skim milk
1 cup frozen, unsweetened strawberries
2 tsp cold-pressed organic flaxseed oil (MUFA)

Combine skim milk and frozen, unsweetened strawberries in blender. Blend, transfer to glass, and stir in flaxseed oil.

Find the Pill That's Right For You

The birth control pill is the world's most popular form of contraception, and it's pretty easy to see why: The Pill is highly effective and easy to use, and it can slash your risk of serious health problems like osteoporosis and ovarian cancer. But with more than 50 different brands on the market, it can be tough to choose one. "Many women experiment with a few different types before they find one they like," says Mary Jane Minkin, M. D., clinical professor of obstetrics and gynecology at Yale University School of Medicine. Consult our chart to pinpoint the one that suits you best.

If You Have: Persistent acne
Try This: Ortho Tri-Cyclen
Why It's Best: All women produce some testosterone, which can increase oil production and bring on breakouts. Ortho Tri-Cyclen contains the skin-friendly hormone norgestimate, which helps decrease your body's testosterone levels.

If You Have: Wicked PMS
Try This: Yaz or Yasmin
Why It's Best: Both contain drospirenone, a hormone that minimizes water retention, which can help reduce bloating. Plus, a study found that taking Yaz helps reduce severe pre-period mood swings.

If You Have: Heavy or painful periods
Try This: Seasonale, Seasonique, or Lybrel
Why It's Best: All oral contraceptives can help lighten your flow, but extended-cycle pills can significantly reduce or even end painful bleeding by slashing the number of periods you get per year—just four with Seasonale and Seasonique, and zero with Lybrel.

If You Have: A new baby
Try This: Nor-Qd, Orthomicronor, or other progestin only pills
Why It's Best: Pills that contain estrogen can decrease breast-milk production by up to 5 percent. Progestin-only pills don't interfere with lactation; just make sure you take them at the same time every day or you could end up with another little bundle of joy earlier than planned. Their effectiveness rate is slightly lower than combination-hormone pills—92 percent versus 98 percent.

If You Have: Menstrual migraines
Try This: Mircette
Why It's Best: You usually get your period on placebo-pill days; this is also when migraines most often strike, thanks to the rapid drop in estrogen. Each pack of Mircette contains only two placebos rather than the usual seven, cutting your number of headache-prone days.

If You Have: Breakthrough bleeding
Try This: Femcon Fe or another low-dose estrogen pill
Why It's Best: Compared with other brands, this one gives a lower dose of estrogen, helping to minimize breakthrough bleeding. Bonus: These pills are mint flavored and chewable!

Agony of the Feet

It Grows On You, aka BUNIONS
Looks like A bony lump on the outer edge of your big toe.
Happens when The lowest joint becomes misaligned, causing the end of the bone to jut out. Though pointy heels that squash your toes can make bunions more painful, shoes are not the cause. More crucial factors are the shape of your feet and the way you walk.
How to deal Buy footwear made of stretchy material, such as leather, that will conform to the curves of your foot. Before throwing down your plastic, hold the sole of the shoe against the sole of your foot to make sure the toe box is at least as wide as your tootsies. Using custom insoles, which any podiatrist can provide, may prevent bunions from worsening, but surgery is the only real cure. Still, docs don't recommend it unless the pain is so bad you can't function normally. Most procedures involve shaving down the bone and realigning the toe with a pin or a screw, which leaves you hobbling around for one to two months afterward. Plus, stubborn bunions come back in 10 to 15 percent of cases.
MC Freaky Feet aka HAMMERTOES
Looks like The joint of one of your toes (usually the second piggy) points upward instead of lying flat.
Happens when A bunion, flat or high arches, or too-narrow shoes cause your big toe to butt up against the second toe, putting pressure on the digit and causing it to contract.
How to deal A Budin splint--a flat, foamy pad with an elastic loop that goes under the ball of your foot and wraps around the hammertoe--can reduce pressure and friction from shoes. A podiatrist can also give you cortisone shots to tame the pain. If you've tried those options and are still desperate, surgery offers permanent relief. A small piece of bone on one or both sides of the joint is removed so the toe can uncurl, and a pin is sometimes left in for a few weeks to keep it in place.

Rubbed the wrong way aka CORNS AND CALLUSES
Looks like Raised layers of thick, dead skin. On the tops of your toes they're called corns; on the bottoms or sides of your feet they're known as calluses.
Happens when There's too much pressure or friction on the feet, often due to ill-fitting shoes or a deformity, like a hammertoe.
How to deal Once or twice a week, in the shower, gently rub the area with a pumice stone until the skin begins to turn pink. Follow with a cream designed to soften calloused skin, such as Gordon Laboratories Gormel creme with 20 percent urea ($13 for 2.5 oz, amazon.com). If the layers are really thick, have a podiatrist shave them down during an in-office medical pedicure (because there's a risk of infection, stay away from the nail salon for this). Avoid OTC medicated pads containing salicylic acid, which can burn healthy skin and cause infection.

Hell on heels aka PLANTAR FASCIITIS
Feels like A stabbing or burning pain in your heel that's often worse in the morning.
Happens when The plantar fascia, a band of tissue that runs from the heel to the ball of the foot, becomes inflamed. This can be triggered by the strain of having exceptionally flat or high arches, standing or walking all day long, being overweight, or doing intense physical activities.
How to deal Try OTC arch supports or custom insoles to take stress off the plantar fascia and a topical gel called Biofreeze, also at drugstores, to increase blood flow and ease the ouch. If you're really in agony, ultrasound therapy and shock-wave therapy can speed healing. There's also a new, minimally invasive surgery called an endoscopic plantar fasciotomy, in which a surgeon makes a tiny snip into the plantar fascia to release the tense tissue. However, a study found that up to 25 percent of people who have this surgery continue to experience pain.

In a pinch aka NEUROMA
Feels like Tingling, burning, or numbness in your foot. It may make you feel as if you're walking on a pebble.
Happens when The bones of two toes--usually the third and fourth ones--rub against one another, pinch­ing the nerve in between. Too-narrow shoes, which cram toes together, are often to blame.
How to deal Most experts recommend cortisone injections, to reduce pain, or alcohol, which will destroy a portion of the nerve. If your foot is still killing you despite the shots, surgery can cut out the squashed nerve.